Femur originated genu varum in a patient with symptomatic ACL deficiency: a case report and review of literature
BMC Musculoskeletal Disorders volume 22, Article number: 437 (2021)
Anterior cruciate ligament (ACL) injury may be associated with genu varum. There are a few indications in which the varus deformity can be corrected at the time of ACL reconstruction. However, as the genu varum originates mostly from the tibia and the simultaneous presence of ACL deficiency and femur originated genu varum is uncommon, only a few papers have described their management for ACL deficient patients with femur originated genu varum.
A young patient visited our clinic with a complaint of right knee pain and giving way. Further work up revealed a full mid substance ACL tear, mild medial knee osteoarthritis and femur originated genu varum of his right knee. He was managed with simultaneous ACL reconstruction and distal femoral valgus osteotomy.
Any corrective osteotomy for genu varum should be performed at center of rotation angle. Isolated ACL reconstruction in patients with simultaneous ACL deficiency and genu varum may hasten the knee degeneration.
Level of evidence
Knee valgus osteotomy combined with Anterior Cruciate Ligament reconstruction (ACL-R) should be considered in active young patients with genu varum (varus angle > 5 degrees) and symptomatic ipsilateral Anterior Cruciate Ligament (ACL) deficiency if the affected knee has either medial compartment Osteoarthritis (OA) or lateral thrust (double varus) .
Among 650 cases of symptomatic ACL deficiency referred to our center during the three-years period (2016–2019), 8 patients had a genu varum plus either medial knee OA or lateral thrust and only one of them had femur originated genu varum. As the genu varum originates mostly from tibia and the simultaneous presence of ACL deficiency and femur originated genu varum is uncommon, only a few papers have described their management for ACL deficient patients with femur originated genu varum .
In this study, a young patient with symptomatic ACL deficiency, femur originated genu varum and mild medial OA of the right knee is reported. He was treated with simultaneous medial opening wedge distal femoral osteotomy (DFO) and ACL-R This report is presented according to the SCARE criteria as proposed by Agha et al. .
Our patient was a 29-year-old man complaining of medial knee pain and giving way of his right knee for 2 years since a previous sport injury. His past medical history and drug history were negative.
During physical examination, the patient had no genu recurvatum. His Anterior Drawer Test (ADT) was positive with a 10 mm anterior subluxation. His Lachman and Pivot shift tests were positive. In addition to varus malalignment (varus angle 7 degrees), a lateral thrust was evident during his gait performance.
The Magnetic Resonance Imaging (MRI) confirmed ACL tear of his right knee. Our patient had double varus based on Noyes’s grading . His Lysholm and International Knee Documentation Committee (IKDC) score were 26 and 29.8 respectively. The Visual Analogue Scale (VAS) score of his preoperative right knee pain was 8.
Based on the patient’s standing triple joints alignment view, our patient’s varus angle was 7o and according to his Medial Proximal Tibial Angle (MPTA) (90.83o) and Lateral Distal Femoral Angle (LDFA) (92.21o), the varus deformity was assumed to be of femoral origin (Fig. 1). So, it was decided to perform distal femoral valgus osteotomy to correct varus malalignment. No significant femoral/ tibial length discrepancy existed comparing both sides (femoral and tibial length of 492 and 413 mm on the right side consecutively; femoral and tibial length of 493 and 417 mm consecutively on the left side). Instead of lateral closing wedge osteotomy, it was preferred to perform medial side opening wedge valgus osteotomy as the former might interfere with femoral tunnel drilling during ACL-R. Using the mediCAD ® software, it was analyzed that at the osteotomy opening, the angle between proximal and distal fragments should be increased to 7 degrees and the space between the proximal and distal fragments should be increased to 10 mm at the medial cortex.
The patient was placed in a supine position. The involved lower limb was hung hyper-flexed with a leg holder. A prophylactic dose of Cefazolin (1 gram) and tranexamic acid (TXA) (1 gr) was administered intravenously 30 min and 1 h before the surgery consecutively. A same intravenous (IV) dose of TXA (1 gr) was repeated at the end of the surgery. A tourniquet was applied during the surgical procedure.
Arthroscopy was performed through standard anteromedial and anterolateral portal. A mid substance tear in ACL plus 1cm2 chondral lesion in medial femoral condyle were diagnosed (Fig. 2). The stump of the ACL was removed. Then, chondral abrasion and micro fracturing was performed to stimulate the regeneration of chondral lesion (Fig. 3). No meniscal lesion was detected.
A 3 cm vertical incision was made on the anteromedial tibial cortex initiating at 1 cm distal to the joint line of the knee. The sartorial fascia was dissected and the Semitendinous and Gracilis tendons were recognized. All vincula of both tendons were released carefully and tendon stripper was then used to harvest Gracilis and Semitendinous autograft.
After diagnostic arthroscopy, the knee was extended and the leg was placed on a Mayo table. A longitudinal incision on anteromedial side of the right thigh was created starting from 10 cm above the upper border of the patella to 2 cm bellow the patella’s upper border. The distal femur was exposed through subvastus approach. The joint capsule was left intact. Under fluoroscopic guidance, two pins were placed from 55 mm proximal to the joint line on the medial side to just proximal to the lateral femoral condyle. The first pin was inserted at the intersection of anterior one third and posterior two thirds of the femur and the second one was applied in the intersection of posterior one third and anterior two thirds of the femur in parallel to the first one (Fig. 4).
Biplanar osteotomy was performed from medial to lateral direction (Fig. 5). Protecting the soft tissue dorsally with a Hohmann retractor and constantly cooling the oscillating saw blade, a transverse osteotomy cuts was performed in the posterior three fourth of the femur parallel to the path of the inserted pins. In the ventral one fourth of the femur, the osteotomy was performed vertically according to the biplanar osteotomy technique. The vertical osteotomy cut was accomplished with a thinner saw blade to prevent further soft tissue injuries. Posterior cortex was cut with manual broad osteotome to protect the neurovascular structures. During the osteotomy, one centimeter of the cortex on the lateral side was kept intact to function as a hinge during the wedge insertion.
Careful opening of osteotomy site was performed gradually with variable sized chisel osteotome to save the lateral femoral cortex. Lamina spreader was placed to insert the wedge shape corticocancellus allograft.
The osteotomy was stabilized with TomoFix Medial Distal Femur Plate (Synthes®) placed anteromedially (Fig. 6). Four bicortical screws were applied at the proximal segment and 4 unicortical screws were used at the distal fragment in such a way not crossing the midline.
In the next step, the leg was hung on the leg holder again and the femoral and tibial canals were created arthroscopically. The harvested hamstring autograft was passed through the tibial and femoral tunnel. It was fixed proximally by flipping an endo-button on the lateral femoral cortex and distally to the tibia by interference bioabsorbable screw. After careful hemostasis and wound irrigation with sterile normal saline, the surgical incision was repaired without placing any drainage catheter.
Following the surgery, the patient was allowed to start range of motion. Partial weight bearing in a hinge knee brace was permitted during the first 6 weeks postoperatively. After 6 weeks, as the clinical and radiologic signs of bone union were observed, the patient was allowed to progress to a full weight bearing status and discontinue the brace. Closed chain exercise was practiced during the first 6 weeks and then, the open kinematic chain exercise was allowed.
Long standing alignment view, at 12 weeks postoperatively, confirmed deformity correction (Fig. 7). The valgus angle was analyzed to be 2o. the detailed alignment variables before and after surgery are depicted in Table 1.
After 6 months, complete union was achieved and our patient’s Lachman and pivot tests were negative. The patient reported no pain during his daily activities (VAS = 0). The amount of anterior subluxation in the ADT was 3mm. The Lysholm and IKDC score were 99 and 94.4 respectively.
The knee with an ACL deficiency presents several problems. Episodes of giving way due to anterior knee instability could result in meniscal tears and degeneration of the articular cartilage . Curado et al. demonstrated that moderate to severe knee OA affects 29 % of ACL deficient patients during a period of 22 years .
Long lasting genu varum imposes greater force on the medial knee compartment, which could cause osteoarthritis as well as degeneration of the articular cartilage .
Dejour et al. demonstrated that isolated ACL reconstruction in ACL deficient knees with accompanying chondral or meniscal injury can paradoxically accelerate the process of OA and result in earlier reoperation . As ACL reconstruction restores the knee stability, it motivates the patient to return to activity and sport faster (permission to abuse the knee). Thus, this might hasten the knee degeneration if the osteoarthritic etiologies (i.e. genu varum, meniscal and knee chondral injury, etc.) is not considered to address simultaneously. While ACL reconstruction stabilizes the knee joint, the valgus osteotomy improves medial knee pain caused by the genu varum, prevents further knee degeneration and decreases the tension on the ACL [4, 7].
Therefore, in those with symptomatic ACL deficiency and medial knee OA due to a varus knee, staged or simultaneous ACL reconstruction and valgus osteotomy is recommended. As simultaneous management of both ACL deficiency and varus deformity in a single operation results in a less recovery time and comparable operative complication than the 2-stage operation, simultaneous ACL-R and valgus osteotomy may be a viable option especially in active young athletic patients [7,8,9,10].
Li et al. performed a systematic review and concluded that ACL-R simultaneously performed with HTO restores the anterior stability of the knee, prevents further advancement of medial knee OA and return patients to sport activity .
Different studies evaluated the return to sport after simultaneous ACL-R and high tibial valgus osteotomy. Bonin et al. demonstrated that around 47 % of patients return to sport activity during a period of 12 years . In comparison, Schneider et al. followed his patients for 10 years and observed 80 % of patients return to sport, while around 30 % gain their preinjury sport activity level .
Despite describing and evaluating simultaneous HTO and ACL-R by many studies, [4, 12,13,14,15], only a few have described simultaneous ACL-R and DFO . In our case, as the deformity had femoral origin (MPTA = 90, LDFA = 92), the valgus osteotomy was carried out in the distal femur.
Different studies revealed that open wedge HTO is associated with increase in posterior tibial slope [16,17,18,19,20]. As posterior tibial slope increases by 10 units, anterior tibial translation increases by 6 millimeters leading to more tension on the ACL . Compared to simultaneous ACL reconstruction and opening wedge HTO, combined ACL reconstruction and DFO does not affect the posterior tibial slope and may have a possible advantage of correcting the knee alignment without increasing the posterior tibial slope.
Regarding our patient, no significant femoral/tibial length discrepancy existed comparing both sides (femoral and tibial length of 492 and 413 mm on the right; femoral and tibial length of 493 and 417 mm consecutively on the left side). Due to this fact and the concern of possible interference of lateral closing wedge DFO and femoral tunnel drilling during ACL reconstruction, in contrast to Moradi et al. study , it was decided to perform a medial opening wedge DFO. After the surgery, the varus angle and the LDFA of the affected knee decreased to the normal level (valgus angle 2, LDFA 85). The MPTA of the same side seems to be decreased from 90.83 to 89. However, as no corrective alignment procedure was performed on the tibia, we believe the nearly 1 degree change in MPTA to be a measurement error. Further studies however, may be needed to compare the results of simultaneous ACL-R with medial opening wedge versus lateral closing wedge DFO, their impact on quality of life and return to sport to further reveal the benefits and limitations of the procedure.
In conclusion, this case report emphasizes that any corrective osteotomy for genu varum should be performed at center of rotation angle. Isolated ACL-R in patients having ACL deficiency and genu varum may lead to increased usage of the affected knee and exacerbate knee degenerative joint disease.
Availability of data and materials
Anterior cruciate ligament
Anterior cruciate ligament reconstruction
Surgical case report
Anterior drawer test
Magnetic resonance imaging
International Knee Documentation Committee
Visual analogue scale
Medial proximal tibial angle
Lateral distal femoral angle
Joint line congruence angle
Proximal tibial posterior slope
- cm2 :
High tibial osteotomy
Distal femoral osteotomy
Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28(3):282–96.
Moradi Amin S, Alireza, Akbar K. The Clinical Outcome of Simultaneous Lateral Closed-Wedge Distal Femoral Osteotomy and Anterior Cruciate Ligament Reconstruction in the ACL-deficient Knees with Symptomatic Femoral Varus Deformity. Archives of Bone Joint Surgery. 2020;8(4):537–44.
Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP. The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg. 2018;60:132–6.
Trojani C, Elhor H, Carles M, Boileau P. Anterior cruciate ligament reconstruction combined with valgus high tibial osteotomy allows return to sports. Orthop Traumatol Surg Res. 2014;100(2):209–12.
Curado J, Hulet C, Hardy P, Jenny JY, Rousseau R, Lucet A, Steltzlen C, Morin V, Grimaud O, Bouguennec N, et al. Very long-term osteoarthritis rate after anterior cruciate ligament reconstruction: 182 cases with 22-year’ follow-up. Orthop Traumatol Surg Res. 2020;106(3):459–63.
Dejour H, Walch G, Deschamps G, Chambat P. Arthrosis of the knee in chronic anterior laxity. Orthop Traumatol Surg Res. 2014;100(1):49–58.
Cantivalli A, Rosso F, Bonasia DE, Rossi R. High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction/Revision. Clin Sports Med. 2019;38(3):417–33.
Boss A, Stutz G, Oursin C, Gächter A. Anterior cruciate ligament reconstruction combined with valgus tibial osteotomy (combined procedure). Knee Surg Sports Traumatol Arthrosc. 1995;3(3):187–91.
Kumahashi N, Kuwata S, Takuwa H, Tanaka N, Uchio Y. Simultaneous anterior cruciate ligament reconstruction and dome-shaped high tibial osteotomy for severe medial compartment osteoarthritis of the knee. Asia-Pacific journal of sports medicine arthroscopy rehabilitation technology. 2016;6:7–12.
Klek M, Dhawan A. The Role of High Tibial Osteotomy in ACL Reconstruction in Knees with Coronal and Sagittal Plane Deformity. Curr Rev Musculoskelet Med. 2019;12(4):466–71.
Li Y, Zhang H, Zhang J, Li X, Song G, Feng H. Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review. Arthroscopy. 2015;31(3):507–19.
Bonin N, Ait Si Selmi T, Donell ST, Dejour H, Neyret P: Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up. The Knee 2004, 11(6):431–437.
Schneider A, Gaillard R, Gunst S, Batailler C, Neyret P, Lustig S, Servien E. Combined ACL reconstruction and opening wedge high tibial osteotomy at 10-year follow-up: excellent laxity control but uncertain return to high level sport. Knee Surg Sports Traumatol Arthrosc. 2020;28(3):960–8.
Jin C, Song EK, Jin QH, Lee NH, Seon JK. Outcomes of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction in anterior cruciate ligament deficient knee with osteoarthritis. BMC Musculoskelet Disord. 2018;19(1):228.
Zaffagnini S, Bonanzinga T, Grassi A, Marcheggiani Muccioli GM, Musiani C, Raggi F, Iacono F, Vaccari V, Marcacci M. Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):934–41.
Ogawa H, Matsumoto K, Akiyama H. Effect of increased posterior tibial slope on the anterior cruciate ligament status in medial open wedge high tibial osteotomy in an uninjured ACL population. Orthop Traumatol Surg Res. 2019;105(6):1085–91.
Jacobi M, Villa V, Reischl N, Demey G, Goy D, Neyret P, Gautier E, Magnussen RA. Factors influencing posterior tibial slope and tibial rotation in opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2762–8.
Lustig S, Scholes CJ, Costa AJ, Coolican MJ, Parker DA. Different changes in slope between the medial and lateral tibial plateau after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):32–8.
Ducat A, Sariali E, Lebel B, Mertl P, Hernigou P, Flecher X, Zayni R, Bonnin M, Jalil R, Amzallag J, et al. Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study. Orthop Traumatol Surg Res. 2012;98(1):68–74.
Jaecker V, Drouven S, Naendrup JH, Kanakamedala AC, Pfeiffer T, Shafizadeh S. Increased medial and lateral tibial posterior slopes are independent risk factors for graft failure following ACL reconstruction. Arch Orthop Trauma Surg. 2018;138(10):1423–31.
Dejour H, Bonnin M. Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. J Bone Joint Surg Br. 1994;76(5):745–9.
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Mortazavi, S.M.J., Noori, A., Vosoughi, F. et al. Femur originated genu varum in a patient with symptomatic ACL deficiency: a case report and review of literature. BMC Musculoskelet Disord 22, 437 (2021). https://doi.org/10.1186/s12891-021-04274-w
- ACL reconstruction
- Knee arthroscopy